F0656

E

Failure to Update Care Plans for Wound, Hearing, and Oxygen Needs

Rio Rancho, New Mexico Survey Completed on 02-11-2026

Penalty

Fine: $17,215

Summary

The deficiency involves the facility’s failure to develop and update comprehensive, person-centered care plans for two residents. One resident was admitted with multiple diagnoses including localized edema, morbid obesity, chronic diastolic heart failure, mixed hyperlipidemia, depression, and essential hypertension. A comprehensive MDS indicated this resident was at risk for developing pressure ulcers. Physician orders dated 09/13/2025 documented a sacral wound with ordered wound care treatment, and the resident reported the wound was acquired in the facility around September 2025. However, review of the care plan dated 09/14/2025 showed no wound care interventions for the sacral wound identified on 09/13/2025, and the DON stated the wound was first identified on 09/11/2025 and confirmed the care plan was not updated at the time of identification, with the first wound care plan entry not appearing until 11/13/2025.

The second resident’s care plan dated 01/07/2026 lacked documentation of problems, goals, or interventions related to auditory assessment or hearing aids, despite issues with hearing and need for hearing aids referenced elsewhere. During interview, the DON stated she was unaware of communication issues and the need for hearing aids for this resident, and acknowledged it was her expectation that the resident’s difficulty hearing be included in the care plan so the team would be aware. The same resident’s care plan documented impaired gas exchange related to respiratory failure and pulmonary edema with several interventions, including adequate fluid intake, elevating the head of the bed, and monitoring for signs of infection, but did not include O2 use as an intervention. The DON confirmed that the resident’s O2 use was not included in the care plan and stated it should have been documented.